PI: Why Obama-plans are WRONG on Universal Healthcare

[Thorgrim]

This is not a 2008-specific post, but rather a UHC post (if we're going to do it...how are we going to do it...not a "should we or shouldn't we" post)

From a poster at Dkos, quoted the entire thing:

The Need for Mandates

1. Broadening the Risk Pool

Obama and Clinton both claim their health plans will make quality coverage affordable for everyone. If this is accomplished, the only people who will not buy health insurance are the people who decide buying health coverage is a poor investment. This group will be much healthier than the group who will choose to buy insurance, as the sick will always see the need for quality, affordable health care.

Insurance is based on pooling risk in a broad manner. Without a mandate, the healthiest members of society will not be in the risk pool. The pool thus contains a disproportionate share of medically needy individuals, spreads the risk over fewer and riskier people, and makes health care more expensive for those who are in the pool.

Clinton's plan mandates that everyone join the pool, bringing the healthy and less-than-healthy together to pool their risks. Spreading the risk over both people who use medical services more often )or costlier medical services) with those who will likely use fewer medical services makes coverage more affordable overall.

Here's a quick breakdown, if that doesn't makes sense:

Person A: Middle aged woman with cervical cancer.
Person B: Man in his mid-30s with a history of knee problems.
Person C: Man in his mid-20s with no known health problems.

If the risk pool contains only A and B, as it likely would under Obama's plan, the price of coverage will be high. Both of those people will likely require expensive care. If C is brought into the risk pool, coverage for A and B becomes much more affordable. The economic risk of insuring A and B is much greater than the risk of insuring all three people.

By mandating insurance, coverage becomes more affordable for the people who need care the most (A and B).

2. Preventing Free Riders

Obama and Clinton both have strong measures in their plans to prevent insurers from discriminating against people who aren't healthy. If someone with a health problem tries to get insurance today, at least one of three things happen:

A) No insurance is offered
B) The pre-existing health problem is excluded from coverage, making the coverage essentially useless.
C) The offer is extremely expensive insurance after underwriting criteria are applied.

Under Obama and Clinton's plans, insurers will not be able to do any of this. They have to offer insurance to everyone, they cannot exclude pre-existing conditions, and they cannot underwrite on the sick. These are all great changes.

However, without mandating coverage, a "free rider" problem is created. Under Obama's plan, healthy people can choose not to buy health insurance until they experience a medical problem. At that point, they can simply buy into a plan with no added cost concerning their sickness.

In essence, they can free ride on the system while they're healthy, and they can just join up when they get sick. They won't be added to the pool until they're high risk, themselves. This increases costs for all.

At one point, Obama suggested he might create a penalty for people who attempt this scheme. There are two problems with this. First, Obama hasn't actually proposed it. Second, it's the same basic problem as underwriting--people will be charged more for coverage if they're sick, which makes it less likely that the people who need care the most will be able to afford it.

Could you imagine if we had a Medicare or Social Security system that allowed free riders? The healthy and wealthy could opt out of the system until something bad happened to their health or their wealth. At that point, they could buy into the system at the last minute and receive all of the same benefits as the people who have been buying into the system since Day 1.

3. Elevating Public Health

While the first two points are about how the people who opt out of the system are screwing the people who opt in, my final point is that people who opt out of the system are also screwing themselves.

Simply put, people are much less likely to go to the doctor for preventive care and general check-ups if they have to pay out of pocket for the doctor's visit. Going all the way back to the classic RAND study on health insurance usage, this realization has been universally accepted in health policy.

The people who opt out of the system under Obama's plan will be less likely to go to the doctor than they would be if they were covered. Two related effects will flow from this, both of which would be avoided under the Clinton plan.

First, the people who opt out will have worse health outcomes. That's obviously bad for them and their families and their communities. Second, failure to receive preventive care means much higher health care costs going forward. An ounce of prevention really is worth a pound of cure.

OBAMA'S CONTRADICTORY ARGUMENTS

Obama's defense of his lack of mandates and attack on Clinton for having mandates make no sense. Let's start with his defense.

Obama claims that he will make health coverage affordable for everyone. He claims that no one would ever refuse to purchase health insurance if it's affordable. Then what's his problem with having a mandate in his plan? If he thinks every American will voluntarily sign up, why would he raise so much vitriol about mandates?

His attack suffers from the same logical disconnect. He claims Clinton's plan will force people to buy coverage they cannot afford. He claims his own plan will make coverage affordable, but he never explains why Clinton's wouldn't. He never explains this, of course, because it's simply not true.

There is absolutely no reason to think Obama's plan would make coverage more affordable than Clinton's plan. In fact, the opposite is true. Bringing healthy people into the system through mandates will make coverage more affordable for the people who are sick.

Obama sets up a false dichotomy between affordability and mandated coverage. In reality, these two are not mutually exclusive. We can make coverage affordable, as Clinton's plan does, while mandating coverage at the same time. There's no contradiction here.

A PERSONAL EXPERIENCE

Obama's attacks on universal coverage strike a nerve with me because of the work I've done and the places I've heard his argument coming from.

A few years ago, I was working for a progressive nonprofit in Washington DC that was part of a coalition to stop a terrible health care bill introduced by Senator Enzi. The bill, modeled after Association Health Plans but oh-so-cleverly renamed Small Business Health Plans, was designed to strip away virtually all state mandated consumer protections in the health insurance market.

Over the past 25 years, state legislatures around the country had passed bills mandating that certain benefits and services be included in all insurance sold in the state. These benefits ranged from cervical cancer and mammography screening to alcoholism treatment to well-child care. The point of the mandates is that if insurers were not required to include them, they could charge exorbitant rates for the people who wanted them included in their individual insurance. Health insurance would be unaffordable for the people who need it most.

Enzi's argument was that we should not be forcing people to buy health coverage they cannot afford. If healthy people want to buy a bare bones package that doesn't include diabetes care, they should be able to.

The essence of Enzi's argument is very much the same as Obama's argument against mandates. They're misleading, dispassionate, and in opposition to the ideals of the Democratic Party. Health care is a right, not a privilege. The only way to secure that right is to make it truly universal.

In case anyone's wondering, we defeated Enzi's bill in the Republican controlled HELP Committee. It was long and hard fight, which is why it pains me so much to have to fight it within our own party. Despite having the support of unions, consumer groups, and most state Insurance Commissioners, our outlook for success was looking grim. But thanks to a strategy hammered out between us and Senator Ted Kennedy (the ranking Democrat on the HELP Committee), we managed to prevent the bill from moving out of committee.

The winning strategy? Forcing Mike Dewine, who was desperately trying to recreate himself as a moderate to hold onto his Ohio Senate seat, to take vote after vote on amendments against cancer, diabetes, asthma, and other benefits and screenings. He, and other moderate Republicans, finally had enough, and the bill died.

When I see Obama's ads, it makes me angry. I think of Michael Enzi. I think of Harry and Louise. I think of AHIP. I think of the 50 million Americans who do not have health coverage. I think of the additional 50 million Americans who are underinsured.

Daily Kos: Universal Health Care: Why Obama is Wrong

The bolded parts pretty much sum up my opinions...so I won't bore you too long...

It's a pain in the ass to do a lot of things in life, make sure your kids are educated (even if you think schools and home schooling are both a waste), getting your drivers license renewed, jury duty, et al

But, do you really want to be on a subway you think is full of diseased people...do you really want to be at work (which has no insurance plan) and see an employee coughing with something really nasty...

I know I've had days where it seemed like the whole city had something disgusting, and speculating that they all didn't have good health insurance, it can not only make you sick, but make simple things like riding a bus more dangerous

Also, it is a basic insurance question...we all know what insurance policies are like if you're just playing it safe but the rest are just in real danger...the risk-part is so high that your safety bet turns out to be something you re-think, even if it is the smart move

Putting EVERYONE in the risk pool, and mandating it...makes everyone interested, which is good for conservatives too, because now you can rightfully complain that your program isn't working right, there can be major reforms, regulations and deregulations, who knows...

However, if we made UHC like Obama would make it...medicare for all who want it...it'll be an entitlement program for the poor and it will never go away or be lowered because it will be seen as an assault on the lower class

[bheld]

It's an assault on the lower class to mandate that they give money they don't have to insurance companies that deny care. It's an assault on every single responsible individual that looks after themselves that they be forced into a group to pay for some other fat slob's diabetes medicine. I'll have to side with the conservatives on this one because Hillary's plan is not the way to use government power.

Hillary's plan takes what is bad about a privatized system and makes it worse. The only ones that benefit are the people that eat at McDonald's all the time because they get to pay less while every other healthy person chips in for their angioplasty. Meanwhile the insurance companies aren't making money by denying sick people from getting coverage, so they deny coverage to everybody at an even higher rate than they're already doing.

The problem is in thinking the current system can be saved. Hillary's plan would be an unmitigated disaster on an unimaginable scale.

The only solution, the ONLY SOLUTION, is to use government to fund healthcare by taxing RISK FACTORS and subsidizing PREVENTION. Without addressing these two things, which only government can do effectively, we're going to have a busted system for years to come.

[Thorgrim]

By your initial logic we should get of medicare and medicaid...because of fat kids and fat elderly persons

The whole point is that the lower class ISN'T forced to pay money they don't have...

You can't deny coverage to someone under Obama or Hillary's UHC, you also can't underwrite

Taxing risk factors is taxing people for their genes...black people have more health problems than white people, we'd have to tax them all at higher rates than white people, how do you think that would go over?

[bheld]

Originally Posted by Thorgrim

By your initial logic we should get of medicare and medicaid...because of fat kids and fat elderly persons

The whole point is that the lower class ISN'T forced to pay money they don't have...

You can't deny coverage to someone under Obama or Hillary's UHC, you also can't underwrite

Taxing risk factors is taxing people for their genes...black people have more health problems than white people, we'd have to tax them all at higher rates than white people, how do you think that would go over?

Medicare and Medicaid are the only things giving people a chance in this country. They're the threads keeping this system from killing even more people. Hillary's plan isn't doing anything to make it better. All it does is take that money and give it to the insurance companies so they can make some profits by being the middleman.

Taxing risk factors means that you tax things that people have choices over. Genetics are the reason we have insurance and spread risk, not somebody's love for McDonald's fries. Government has the ability to tax health risks such as unhealthy food, cigarettes, alcohol, risky behavior while at the same time promote health by subsidizing fitness centers, nutritious food, condoms, etc. In this way we can make sure that the true cost of health care is distributed appropriately.

[Thorgrim]

Medical opinion changes daily on what the "ideal" diet is...you'd have us adjust our dieting habits everytime a medical journal was released to get the best tax benefits

I don't like the taste of wine, yet refusing a glass of wine a day is a choice, I'd be a risk factor for that

It's ridiculous, and there are thousands of more examples, the bill would be the largest in human history and it would be so unwieldy it wouldn't work

I'm sure there would be outrage at skinny people with low cholestoral eating a cheeseburger getting charged extra taxes while a fat person, genetically predisposed to high cholestoral, walks out of the room with lower costs...and at many other choices

If we adopted this plan of yours, we'd have to be either objective and racist, or subjective with "risky" being determined by politicians or whatever your local doctor felt like that day...if "risky" can ever be determined

You act as if there is a magical device that can scan me and determine on a scale of 1-100 how unhealthy i deliberately act

[Thorgrim]

If Medicare and Medicaid are a thread that saves people, so will UHC of Obama/Clinton by ending "death by spreadsheet"

[bheld]

Originally Posted by Thorgrim

If Medicare and Medicaid are a thread that saves people, so will UHC of Obama/Clinton by ending "death by spreadsheet"

How?

[bheld]

Originally Posted by Thorgrim

Medical opinion changes daily on what the "ideal" diet is...you'd have us adjust our dieting habits everytime a medical journal was released to get the best tax benefits

I don't like the taste of wine, yet refusing a glass of wine a day is a choice, I'd be a risk factor for that

It's ridiculous, and there are thousands of more examples, the bill would be the largest in human history and it would be so unwieldy it wouldn't work

I'm sure there would be outrage at skinny people with low cholestoral eating a cheeseburger getting charged extra taxes while a fat person, genetically predisposed to high cholestoral, walks out of the room with lower costs...and at many other choices

If we adopted this plan of yours, we'd have to be either objective and racist, or subjective with "risky" being determined by politicians or whatever your local doctor felt like that day...if "risky" can ever be determined

You act as if there is a magical device that can scan me and determine on a scale of 1-100 how unhealthy i deliberately act

Tell me how complicated is it to tax cigarettes and alcohol? How complicated is it to re-appraise our farm bill so that we can actually subsidize healthy foods instead of what agribusiness gets rich on? Why can't we have a tax based on the fat content of foods? That's not subjective or racist. We know all of that stuff would be effective.

There's no reason to think this isn't a workable solution. It's going to take commitment but it's the best way to solve the problem. Everything else is just a band-aid.

[Thorgrim]

Anyone in Congress can tell you the farm bill is incredibly complicated

Americans would not go for extra taxes on fast food...that's a tax on the poor as of now, anything more radical would be rejected by the Senate and the people as "communist"

We already tax cigarettes and alcohol, and there are bills that will raise taxes on cigarettes...alcohol, doctors are saying is good for us...so why tax it more?

It doesn't "take commitment" it takes an approach that can get 60 senate votes

Your plan is not that, you have to be realistic, or accept nothing

[bheld]

Originally Posted by Thorgrim

Anyone in Congress can tell you the farm bill is incredibly complicated

Americans would not go for extra taxes on fast food...that's a tax on the poor as of now, anything more radical would be rejected by the Senate and the people as "communist"

We already tax cigarettes and alcohol, and there are bills that will raise taxes on cigarettes...alcohol, doctors are saying is good for us...so why tax it more?

It doesn't "take commitment" it takes an approach that can get 60 senate votes

Your plan is not that, you have to be realistic, or accept nothing

More focus on what we can't do. I guess I don't subscribe to your pessimistic view. What's the point of even talking about it if we're just going to accept the path of least resistance? Sure, it would be easier to just pass a bill that says insurance companies have to do everything the government tells them to and that every person has to get health insurance or else, but you're telling me that the American people are going to go for that over a plan that actually tries to be fair about it but in a way that people aren't stuck on their own?

[Thorgrim]

That's exactly what they did in 1993, after electing a president running on universal healthcare, they chose to not care about the issue for 15 years